Clinical Decision-Making by Acute Medicine Advanced Nurse Practitioners

Abstract

Background The Acute Medicine Advanced Nurse Practitioner (ANP) role has become one of the innovative strategies employed by the National Health Service (NHS) to address the challenges of the speciality of Acute Medicine. Clinical decision-making is regarded as the cornerstone of accountability. Nursing has a much shorter tradition of medical clinical decision-making. There continues to be a battle between specifying the philosophies underpinning education, preparation and the expectations of the public. The current literature is heavily influenced by theoretical discussion around the definition of an ANP, the conceptualisation of Advanced Practice, the quest for autonomy, the medicalisation of the nursing profession influencing scope of practice and the integration of evidence based practice. There is no previous research into clinical decision-making by Acute Medicine ANPs. To ensure quality clinical decision-making and enable appropriate education and training it is imperative to gain a thorough understanding of the factors that influence the clinical decisions of Acute Medicine ANPs in the context of real life practice. Methods An ethnographic case study approach was employed to examine clinical decision-making by ten Acute Medicine ANPs in Acute Medicine from three NHS sites (Site 1: 6 Acute Medicine ANPs, Site 2: 2 Acute Medicine ANPs and Site 3: 2 Acute Medicine ANPs). The research study was conducted in the context of the natural world of the research participants. Data were gathered through varying levels of observation from unobtrusive to participant during Acute Medicine ANP clinical encounters with patients and during the following informal interviews. Field notes from the clinical encounters and the informal interviews were documented in a double-entry notebook. The field notes were then expanded into descriptive text and then further into extended narratives to encompass forty case studies (Site 1: 24 case studies, Site 2: 10 case studies and Site 3: 6 case studies). Data collection for the fifteen formal interviews conducted away from the clinical environment (Site 1: 9 formal interviews, Site 2: 4 formal interviews and Site 3: 2 formal interviews) were audio-recorded and transcribed to provide an accurate account and contributed to extended narratives. The data collection phase of the research study reached saturation after one year. The analysis of the data was an iterative process that required ongoing comparison and contrasting between incidents found in the data and the emerging theoretical concepts. Quirkos (computer software designed to aid qualitative data analysis) was employed to assist in the organising and analysis of the large volume of data. This process was enhanced through a shared experience by exposing the themes to the research participants and research supervisors to ensure that the data had descriptive value. 4 Findings Acute Medicine is a complex and nuanced healthcare environment characterised by an atmosphere of unrelenting tension and high pressure demands. The discussion is organised around Dual-Process Theory, clinical decision-making and the themes: Decisiveness (the ability to commit to a decision); and Indecisiveness (the consideration of multiple alternative possibilities) identified in the data. System 1 reasoning processes are connected to experience and priori knowledge. The abstract hypothetical thinking of System 2 reasoning processes are required in situations of complexity, uncertainty and in the absence of an anchor. The Acute Medicine ANP is more decisive when there is no gap between what is known and what needs to be known. The degree of uncertainty or certainty varies depending upon how much knowledge can be established regarding the presented clinical situation. The absence or limitation of unknown factors lends itself to less potential for uncertainty to intrude upon the clinical decision-making process. The concept of ‘common’ and ‘decisiveness’ are linked and that the combination of these two lends itself to the notion of experience. Conclusion Clinical decision-making by the Acute Medicine ANP is a process of diverse levels of complexity that they undertake multiple times on a daily basis. This research has identified constructs, patterns of behaviour and attitudes that may be comparable and translatable to other similar complex and nuanced healthcare environments and the ANPs that ply their trade in them.